Identifying and Advocating Best Practices in the Criminal Justice System. A Texas-Centric Examination of Current Conditions, Reform Initiatives, and Emerging Issues with a Special Emphasis on Capital Punishment.

The stress of two planned executions in one day, a lack of proper equipment and no backup plan hampered Clayton Lockett's execution, according to a report released today.

The report, released today by the Department of Public Safety, also found that DOC lacked a longer needle and other equipment that medical professionals requested to insert the IV. It also states that officials took no steps to revive Lockett after his execution went awry and the blinds were closed.

Gov. Mary Fallin’s staff began preparing a stay of execution for Lockett but he died before it could be issued, the report states.

“There was conversation inside the chamber about administering life-saving measures to Lockett, including transporting him to the emergency room, but no order was given,” the report states.

Among the investigation’s findings was that “the IV access point was the single greatest factor that contributed to the difficulty in administering the execution drugs.”

It also found that while there were deviations in the state’s execution protocol during the procedure, they did not contribute to complications.

“Despite those deviations, it was determined the protocol was substantially and correctly complied with throughout the entire process,” the report states. “None of the identified deviations contributed to the complications encountered during this execution.”

A timeline of the execution included in the report stated Gov. Mary Fallin’s office told state Corrections Department Director Robert Patton to proceed with the lethal injection, after it became clear only one viable IV had been placed.

The report also sheds light on the moments inside the death chamber that took place after the blinds were closed. According to the investigation’s timeline, a paramedic re-entered the chamber after the blinds were closed to assist the physician in determining the problem with the IV. The physician then observed the lethal drugs had apparently leaked into Lockett’s muscle tissue.

A paramedic and physician inserted the intravenous line in Lockett's groin after failing to find suitable veins in his arms, legs, neck and feet. The report says the IV site was covered with a sheet and not monitored until Lockett began moving unexpectedly after receiving two doses of drugs.

"The physician observed an area of swelling underneath the skin and described it as smaller than a tennis ball, but larger than a golf ball. The physician believed the swelling would have been noticeable if the access point had been viewed during the process," the report said.

The report, the result of an investigation announced by governor Mary Fallin, recommends more training for the medical personnel involved in administering lethal injections and the drafting of a contingency plan should further executions go wrong.

It cites several failures surrounding the insertion of the IV line meant to administer the lethal drugs for the heart attack that ultimately led to Lockett’s death. It says the paramedic who first attempted to insert a needle had no tape with which to secure it, and “before the tape was retrieved, the vein became unviable”.

After two more failed attempts, a physician became involved. State officials also consulted with a physician certified with the American Board of Surgery during the investigation, but did not identify the doctor or clarify if it was the same doctor. Licensed physicians are under strict rules that limit their involvement in executions.

When a vein was finally located in Lockett’s groin, the prison warden requested a sheet to cover the insertion area “to maintain Lockett’s dignity and keep his genital area covered”.

It was that sheet that ultimately complicated the execution. “No one had visual observation of the IV insertion point until it was determined there was an issue and the physician raised the sheet,” the report says. The inability for witnesses and medical personnel to monitor the IV “ led to the issue being discovered several minutes after the execution began”.

Oklahoma state officials have completed a review of April's botched execution of Clayton Lockett and determined that oversights in monitoring the IV line likely contributed to problems witnessed during his prolonged death.

The investigation, conducted by the Oklahoma Department of Public Safety and made public Thursday, concluded that "the viability of the IV access point was the single greatest factor that contributed to the difficulty in administering the execution drugs."

The report largely absolves government officials of direct blame in Lockett's failed execution, which was described as a grisly affair by witnesses and prompted a national conversation about the efficacy of lethal injections as the preferred method of capital punishment in the United States.

And:

The report also lists 10 largely bureaucratic recommendations, including general suggestions such as improving interagency communication, better training of officials, and adoption of consistent "execution terminology." It makes no determination as to the effectiveness of the drugs used in Lockett's execution, including midazolam, a sedative that has been used in three botched executions this year.

Oklahoma Republican Gov. Mary Fallin in May temporarily halted executions in the state and called for a review of its lethal-injection procedures. The state is scheduled to carry out two executions in November and one in December.

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The StandDown Texas Project

The StandDown Texas Project was organized in 2000 to advocate a moratorium on executions and a state-sponsored review of Texas' application of the death penalty.
To stand down is to go off duty temporarily, especially to review safety procedures.

Steve Hall

Project Director Steve Hall was chief of staff to the Attorney General of Texas from 1983-1991; he was an administrator of the Texas Resource Center from 1993-1995. He has worked for the U.S. Congress and several Texas legislators. Hall is a former journalist.